Thought Blocking as a Manifestation of Catatonia: A Case Report.

ABSTRACT: Catatonia is an underrecognized disorder that has been widely described as a psychomotor syndrome, with little emphasis on its thought and cognitive dimensions. The current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision describes only motor and behavioral presentations, whereas a few catatonia scales describe only one form of thought disorders, which is thought perseveration. Thought blocking, a disorder of the thought process, is characterized by regular interruptions in the thought stream. It was described by several scholars as a sign of schizophrenia, with few reports describing thought blocking in association with catatonia. In this article, we describe the course of a patient with bipolar I disorder who presented with catatonia and demonstrated thought blocking. Her catatonic symptoms and thought blocking improved with the addition of lorazepam, recurred upon lorazepam discontinuation, and improved with resumption of lorazepam, demonstrating a clear on/off phenomenon. This report highlights the importance of recognizing thought and cognitive manifestations of catatonia, as it can enhance recognition and improve treatment.

Successful Recovery of a Catatonic Patient with Severe Pneumonia and Respiratory Failure: Modified Electroconvulsive Therapy Following Tracheotomy.

BACKGROUD: Catatonia encompasses a group of severe psychomotor syndromes affecting patients' motor, speech, and complex behaviors. Common features include rigidity, reduced mobility, speech, sputum production, defecation, and eating. Risks associated with catatonia, such as increased muscle tension and reduced swallowing and coughing reflexes, along with risks from therapeutic approaches like prolonged bed rest and sedative drugs, can elevate the risk of aspiration pneumonia, severe pneumonia, and acute respiratory failure. These complications significantly impede catatonia treatment, leading to poor prognosis and jeopardizing patient safety. CASE DESCRIPTION: In this report, we present a case of catatonia complicated by severe pneumonia and respiratory failure, successfully managed with modified electroconvulsive therapy alongside tracheotomy. We hope this case provides valuable insights for psychiatrists encountering similar scenarios, facilitating the development of rational therapeutic strategies for prompt improvement of patient condition.

Catatonia and Delirium: Assessment of Comorbidity, Prevalence, and Therapeutic Response in Medically Ill Inpatients From a University Hospital.

BACKGROUND: Catatonia is a cluster of motor features present in multiple psychiatric and clinical diseases. It may be confused with delirium because both entities are classified according to the type and degree of psychomotor activity. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria for catatonia secondary to medical conditions exclude comorbid catatonia and delirium; besides, there have been increasing reports about a comorbid presentation. This study aimed to describe the prevalence of comorbid catatonia and delirium, the therapeutic response to lorazepam, and the clinical characteristics of patients with an earlier diagnosis of delirium. METHODS: A total of 120 consecutive patients at a university hospital with an earlier diagnosis of delirium were evaluated using the Delirium Scale (confusion assessment method for the intensive care unit) and the Bush-Francis Catatonia Rating Scale for catatonia. In cases of a positive diagnosis of catatonia or catatonia/delirium, a therapeutic trial with intramuscular lorazepam was performed. FINDINGS: Thirty-one patients (26%) were positive for both catatonia and delirium, and 8 patients (7%) had catatonia. Sixty-six patients (55%) were positive only for delirium, and 5 patients (4%) were negative for delirium and catatonia. Lorazepam tests were applied on 22 patients. One in 9 patients with catatonia/delirium responded positively to lorazepam. Patients with catatonia had a 60% positive response rate. CONCLUSIONS: This is the first study on lorazepam use in catatonia-delirium patients; however, further studies are needed to determine the safety and efficacy of lorazepam in these patients. Catatonia and catatonia/delirium are underdiagnosed in inpatient wards and should be routinely assessed in patients with an altered mental status.

Catatonia in adult anti-NMDAR encephalitis: an observational cohort study.

BACKGROUND: Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is one of the most prevalent autoimmune encephalitis and is closely related to catatonia. This study aimed to investigate the clinical features and disease outcomes of adult catatonic anti-NMDAR encephalitis patients. METHODS: Adult patients diagnosed with anti-NMDAR encephalitis between January 2013 and October 2021 were retrospectively enrolled in this study. According to the Bush Francis Catatonia screening instrument (BFCSI), patients were divided into two groups: those with catatonia and those without catatonia. The modified Rankin scale (mRS), Clinical Assessment Scale for Autoimmune Encephalitis (CASE), Neuropsychiatric Inventory (NPI), Patient Health Questionnaire-9 (PHQ-9) and 7-item Generalized Anxiety Disorder Questionnaire (GAD-7) scores were assessed at follow-up. The Mann-Whitney U test (nonparametric), Student's t test (parametric), and chi-squared test were used to analyse the differences between the two groups. RESULTS: Eighty-four patients were recruited, including twenty-five catatonic patients and fifty-nine noncatatonic patients. Among them, 28 had positive antibody only in cerebrospinal fluid (CSF), 4 had positive antibody only in serum and 52 had positive antibody both in CSF and serum. Catatonic patients experienced more disturbance of consciousness (p = 0.01), aggression (p = 0.046) and affective disorders (p = 0.043) than noncatatonic patients. The mRS scores of the catatonia group assessed at admission (p = 0.045) were worse than those of the non-catatonia group. Catatonic patients were more inclined to develop deep vein thrombosis (p = 0.003), decubitus (p = 0.046), pneumonia (p = 0.025), and to be admitted to the intensive care unit (ICU) (p = 0.011) than noncatatonic patients. All patients in the catatonia group received first-line immunotherapy. At the 24-month follow-up, 2 patients in the catatonia group did not achieve good outcomes. At the last follow-up, the catatonia group had more relapses (p = 0.014) and more neuropsychiatric problems (p = 0.035). CONCLUSIONS: Adult anti-NMDAR encephalitis patients with catatonia present distinct clinical features in disease course and are prone to experience more relapses and long-term neuropsychiatric problems than those without catatonia.

Rapid resolution of catatonia secondary to post traumatic stress disorder with secondary psychotic features through scheduled zolpidem tartrate.

Catatonia is a complication of numerous psychiatric and medical conditions. The first-line treatment is typically management of the underlying primary condition as well as scheduled benzodiazepines or electroconvulsive therapy. Electroconvulsive therapy and benzodiazepines are not always tolerated or available when treating patients with catatonia. For this reason, other treatment regimens have been trialed in recent years, including the GABA-modulatory Z drugs such as zolpidem. Some alternative treatment modalities have shown great promise. However, which populaces these are most beneficial for is still unclear. In this article, we examine a case report of a woman who suffered from post-traumatic stress disorder with secondary psychotic features who experienced recurrent akinetic catatonia that was refractory to benzodiazepine therapy. She responded rapidly to scheduled zolpidem with minimal side effects. It is our author's belief that when managing catatonia in patients with post traumatic stress disorder with secondary psychosis, Z drugs may be preferable to benzodiazepines.

Catatonia during COVID-19 pandemic - diagnostic and therapeutic approach.

Catatonia can be defined as an etiologically heterogeneous syndrome, with predominant psychomotor disturbances. Historically, the concept of catatonia has been associated with mental disorders, especially schizophrenia. However, nowadays our understanding of catatonia has evolved to recognize it as neuropsychiatric syndrome that can arise from diverse etiological factors ranging from neurological to systemic diseases. Furthermore, there is now a recognized association between catatonia and a broader spectrum of mental disorders. Catatonia as a secondary neuropsychiatric syndrome may be a clinical manifestation of COVID-19 also due to the known neuroinvasive potential of the SARS-CoV-2 virus or in connection with the overall somatic alteration of the patient. In clinical practice, co-infection with SARS-CoV-2 could impede the process of diagnosing and treating catatonia as the primary psychopathological syndrome. The administration of benzodiazepines and electroconvulsive therapy could endanger the patient's physical health with active COVID-19 infection. Management of catatonic syndrome associated with COVID-19 is a challenge and requires a comprehensive therapeutic approach. The article demonstrates the above-mentioned difficulties of treatment through two case presentations (Tab. 2, Ref. 29). Text in PDF www.elis.sk Keywords: catatonia, COVID-19, SARS-CoV-2, neuropsychiatry, diagnosis, differential.

Antipsychotics for schizophrenia spectrum disorders with catatonic symptoms.

BACKGROUND: Whilst antipsychotics are the mainstay of treatment for schizophrenia spectrum disorders, there have been numerous attempts to identify biomarkers that can predict treatment response. One potential marker may be psychomotor abnormalities, including catatonic symptoms. Early studies suggested that catatonic symptoms predict poor treatment response, whilst anecdotal reports of rare adverse events have been invoked against antipsychotics. The efficacy and safety of antipsychotics in the treatment of this subtype of schizophrenia have rarely been studied in randomised controlled trials (RCTs). OBJECTIVES: To compare the effects of any single antipsychotic medication with another antipsychotic or with other pharmacological agents, electroconvulsive therapy (ECT), other non-pharmacological neuromodulation therapies (e.g. transcranial magnetic stimulation), or placebo for treating positive, negative, and catatonic symptoms in people who have schizophrenia spectrum disorders with catatonic symptoms. SEARCH METHODS: We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PubMed, ClinicalTrials.gov, the ISRCTN registry, and WHO ICTRP, on 19 September 2021. There were no language, date, document type, or publication status limitations for inclusion of records in the register. We also manually searched reference lists from the included studies, and contacted study authors when relevant. SELECTION CRITERIA: All RCTs comparing any single antipsychotic medication with another antipsychotic or with other pharmacological agents, ECT, other non-pharmacological neuromodulation therapies, or placebo for people who have schizophrenia spectrum disorders with catatonic symptoms. DATA COLLECTION AND ANALYSIS: two review authors independently inspected citations, selected studies, extracted data, and appraised study quality. For binary outcomes, we planned to calculate risk ratios and their 95% confidence intervals (CI) on an intention-to-treat basis. For continuous outcomes, we planned to calculate mean differences between groups and their 95% CI. We assessed risk of bias for the included studies, and created a summary of findings table; however, we did not assess the certainty of the evidence using the GRADE approach because there was no quantitative evidence in the included study. MAIN RESULTS: Out of 53 identified reports, one RCT including 14 hospitalised adults with schizophrenia and catatonic symptoms met the inclusion criteria of the review. The study, which was conducted in India and lasted only three weeks, compared risperidone with ECT in people who did not respond to an initial lorazepam trial.   There were no usable data reported on the primary efficacy outcomes of clinically important changes in positive, negative, or catatonic symptoms. Whilst both study groups improved in catatonia scores on the Bush-Francis Catatonia Rating Scale (BFCRS), the ECT group showed significantly greater improvement at week 3 endpoint (mean +/- estimated standard deviation; 0.68 +/- 4.58; N = 8) than the risperidone group (6.04 +/- 4.58; N = 6; P = 0.035 of a two-way analysis of variance (ANOVA) for repeated measures originally conducted in the trial). Similarly, both groups improved on the Positive and Negative Syndrome Scale (PANSS) scores by week 3, but ECT showed significantly greater improvement in positive symptoms scores compared with risperidone (P = 0.04). However, data on BFCRS scores in the ECT group appeared to be skewed, and mean PANSS scores were not reported, thereby precluding further analyses of both BFCRS and PANSS data according to the protocol.  Although no cases of neuroleptic malignant syndrome were reported, extrapyramidal symptoms as a primary safety outcome were reported in three cases in the risperidone group. Conversely, headache (N = 6), memory loss (N = 4), and a prolonged seizure were reported in people receiving ECT. These adverse effects, which were assessed as specific for antipsychotics and ECT, respectively, were the only adverse effects reported in the study. However, the exact number of participants with adverse events was not clearly reported in both groups, precluding further analysis.  Our results were based only on a single study with a very small sample size, short duration of treatment, unclear or high risk of bias due to unclear randomisation methods, possible imbalance in baseline characteristics, skewed data, and selective reporting. Data on outcomes of general functioning, global state, quality of life, and service use, as well as data on specific phenomenology and duration of catatonic symptoms, were not reported. AUTHORS' CONCLUSIONS: We found only one small, short-term trial suggesting that risperidone may improve catatonic and positive symptoms scale scores amongst people with schizophrenia spectrum disorders and catatonic symptoms, but that ECT may result in greater improvement in the first three weeks of treatment. Due to small sample size, methodological shortcomings and brief duration of the study, as well as risk of bias, the evidence from this review is of very low quality. We are uncertain if these are true effects, limiting any conclusions that can be drawn from the evidence. No cases of neuroleptic malignant syndrome were reported, but we cannot rule out the risk of this or other rare adverse events in larger population samples.  High-quality trials continue to be necessary to differentiate treatments for people with symptoms of catatonia in schizophrenia spectrum disorders. The lack of consensus on the psychopathology of catatonia remains a barrier to defining treatments for people with schizophrenia. Better understanding of the efficacy and safety of antipsychotics may clarify treatment for this unique subtype of schizophrenia.

ANTECEDENTES: Aunque los antipsicóticos son la base del tratamiento de los trastornos del espectro de la esquizofrenia, ha habido numerosos intentos de identificar biomarcadores que puedan predecir la respuesta al tratamiento. Un posible marcador podrían ser las anomalías psicomotoras, incluidos los síntomas catatónicos. Los estudios más antiguos indican que los síntomas catatónicos predicen una respuesta deficiente al tratamiento, mientras que se han alegado informes anecdóticos de eventos adversos poco frecuentes contra los antipsicóticos. La eficacia y la seguridad de los antipsicóticos en el tratamiento de este subtipo de esquizofrenia rara vez se han estudiado en ensayos controlados aleatorizados (ECA). OBJETIVOS: Comparar los efectos de cualquier fármaco antipsicótico único con otro antipsicótico o con otros agentes farmacológicos, terapia electroconvulsiva (TEC), otras terapias de neuromodulación no farmacológicas (p. ej., estimulación magnética transcraneal) o placebo para el tratamiento de los síntomas positivos, negativos y catatónicos en personas que presentan trastornos del espectro de la esquizofrenia con síntomas catatónicos. MÉTODOS DE BÚSQUEDA: El 19 de septiembre de 2021 se realizaron búsquedas en el registro de ensayos basados en estudios del Grupo Cochrane de Esquizofrenia (Cochrane Schizophrenia Group), que se basa en CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PubMed, ClinicalTrials.gov, el registro ISRCTN y la ICTRP de la OMS. No hubo limitaciones de idioma, fecha, tipo de documento o estado de publicación para la inclusión de los registros en el registro. También se realizaron búsquedas manuales en las listas de referencias de los estudios incluidos y se estableció contacto con los autores de los estudios cuando fue pertinente. CRITERIOS DE SELECCIÓN: Todos los ECA que compararan cualquier fármaco antipsicótico único con otro antipsicótico o con otros agentes farmacológicos, TEC, otras terapias de neuromodulación no farmacológicas o placebo en personas que presentan trastornos del espectro de la esquizofrenia con síntomas catatónicos. OBTENCIÓN Y ANÁLISIS DE LOS DATOS: Dos autores de la revisión inspeccionaron de forma independiente las citas, seleccionaron los estudios, extrajeron los datos y evaluaron la calidad de los estudios. Para los desenlaces binarios se planeó calcular las razones de riesgos y sus intervalos de confianza (IC) del 95% sobre la base de la intención de tratar. Para los desenlaces continuos se planeó calcular las diferencias de medias entre los grupos y sus IC del 95%. Se evaluó el riesgo de sesgo de los estudios incluidos y se creó una tabla de resumen de los hallazgos. Sin embargo, no se evaluó la certeza de la evidencia mediante el método GRADE porque no hubo evidencia cuantitativa en el estudio incluido. RESULTADOS PRINCIPALES: De los 53 informes identificados, un ECA que incluyó a 14 adultos hospitalizados con esquizofrenia y síntomas catatónicos cumplió con los criterios de inclusión de la revisión. El estudio, realizado en la India y que sólo duró tres semanas, comparó la risperidona con la TEC en personas que no respondieron a una prueba inicial con lorazepam. No se informaron datos utilizables sobre los desenlaces principales de eficacia de cambios clínicamente importantes en los síntomas positivos, negativos o catatónicos. Aunque ambos grupos del estudio mejoraron en las puntuaciones de catatonia en la Bush­Francis Catatonia Rating Scale (BFCRS), el grupo de TEC mostró una mejoría significativamente mayor en el desenlace a las tres semanas (media +/­ desviación estándar estimada; 0,68 +/­ 4,58; n = 8) que el grupo de risperidona (6,04 +/­ 4,58; n = 6; p = 0,035 de un análisis de varianza (ANOVA) de dos vías para medidas repetidas realizado originalmente en el ensayo). Asimismo, ambos grupos mejoraron en las puntuaciones de la Positive and Negative Syndrome Scale (PANSS) a las tres semanas, pero la TEC mostró una mejoría significativamente mayor en las puntuaciones de los síntomas positivos en comparación con la risperidona (p = 0,04). Sin embargo, los datos sobre las puntuaciones de la BFCRS en el grupo de TEC parecieron estar sesgados, y no se informaron las puntuaciones medias de la PANSS, lo que impidió realizar más análisis de los datos de la BFCRS y la PANSS según el protocolo. Aunque no se informaron casos de síndrome neuroléptico maligno, en tres casos del grupo de risperidona se notificaron síntomas extrapiramidales como un desenlace principal de seguridad. Por el contrario, en las personas que recibieron TEC se informó cefalea (n = 6), pérdida de memoria (n = 4) y una convulsión prolongada. Estos efectos adversos, que se evaluaron como específicos de los antipsicóticos y de la TEC, respectivamente, fueron los únicos efectos adversos notificados en el estudio. Sin embargo, el número exacto de participantes con eventos adversos no se informó claramente en ambos grupos, lo que impidió realizar un análisis más profundo. Los resultados de esta revisión se basaron en un solo estudio con un tamaño muestral muy pequeño, una duración corta del tratamiento, un riesgo de sesgo incierto o alto debido a métodos de asignación al azar poco claros, un posible desequilibrio en las características iniciales, datos sesgados y un informe selectivo. No se informaron datos sobre los desenlaces de funcionalidad general, estado global, calidad de vida ni uso de los servicios, así como tampoco datos sobre la fenomenología específica ni la duración de los síntomas catatónicos. CONCLUSIONES DE LOS AUTORES: Solo se encontró un ensayo pequeño, a corto plazo, que indica que la risperidona podría mejorar las puntuaciones de la escala de síntomas catatónicos y positivos entre las personas con trastornos del espectro de la esquizofrenia y síntomas catatónicos, pero que la TEC podría producir una mayor mejoría en las primeras tres semanas de tratamiento. Debido al pequeño tamaño muestral, las deficiencias metodológicas y la breve duración del estudio, así como el riesgo de sesgo, la evidencia de esta revisión es de calidad muy baja. No hay confianza en que estos efectos sean verdaderos, lo que limita cualquier conclusión que se pueda sacar a partir de la evidencia. No se notificaron casos de síndrome neuroléptico maligno, pero no se puede descartar el riesgo de este u otros eventos adversos poco frecuentes en muestras poblacionales más grandes. Aún se necesitan ensayos de calidad alta para diferenciar los tratamientos en las personas con síntomas de catatonia en los trastornos del espectro de la esquizofrenia. La falta de consenso sobre la psicopatología de la catatonia todavía es un obstáculo para definir los tratamientos para las personas con esquizofrenia. Un mejor conocimiento de la eficacia y la seguridad de los antipsicóticos podría aclarar el tratamiento de este subtipo único de esquizofrenia.

[Delirium, catatonia and substance withdrawal syndrome manifested as psychomotor agitation in COVID-19: a pharmacological management approach for the general hospital setting]. / Delirium, catatonía y síndrome de abstinencia manifestados como agitación psicomotora en COVID-19: una propuesta de manejo farmacológico en el hospital general.

BACKGROUND: Neuropsychiatric symptoms can be part of the clinical spectrum of COVID-19 infections. AIM: To devise an evidence based clinical algorithm as a guide for clinicians, to identify and treat underlying clinical syndromes of psychomotor agitation, such as delirium, catatonia or substance withdrawal in patients who are hospitalized and infected with SARS-CoV-2. MATERIAL AND METHODS: A review of the literature about the pharmacological management of neuropsychiatric manifestations of COVID-19 at the general hospital, to develop a clinical protocol based on a consensus from an interdisciplinary expert panel at a Clinical Hospital. RESULTS: A consensual clinical algorithm for the management of delirium, catatonia, and substance withdrawal, manifested as psychomotor agitation in patients hospitalized with COVID-19, was developed as a clinical proposal for physicians at different levels of complexity in health services. CONCLUSIONS: Cooperation among different clinical units in the general hospital facilitated the implementation of a clinical algorithm for clinicians for the management of psychomotor agitation in COVID-19 patients.

Psychiatric management of anti-NMDAR encephalitis: a cohort analysis.

BACKGROUND: Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis is an immune-mediated disorder which requires multi-disciplinary treatment including immunomodulation therapy. First presentation is most commonly to psychiatric services and continuing psychiatric care is required to treat disabling symptoms, such as behaviour disturbance, psychosis and catatonia. There is minimal available evidence to guide symptomatic treatment and concern for increased sensitivity to antipsychotics complicates traditional approaches. METHODS: All cases of cerebrospinal fluid positive anti-NMDAR encephalitis tested in Queensland, Australia were identified. Demographic, clinical and therapeutic data were collected and reviewed by two independent clinicians. Pre-specified variables reflecting possible treatment side effects were compared. RESULTS: The majority of the 30 cases (83%) had early psychiatric symptoms and were treated with antipsychotics (67%), average daily olanzapine equivalence dose of 11.5 mg, prior to immunomodulation therapy. Although there was an 88% reduction in cases with aggression, there was little improvement in psychosis, affective symptoms or catatonia with antipsychotics alone. In the cases with psychiatric symptoms, there was no significant difference in the rate of occurrence of neurological and autonomic symptoms between cases prescribed and not prescribed antipsychotics. CONCLUSIONS: Psychiatric input is imperative for both acute and longer-term management of anti-NMDAR encephalitis. Primary symptomatic treatment should remain immunotherapy and surgery. Antipsychotic medications have particular value in managing agitation and aggression. Potential side effects from antipsychotic treatment are difficult to differentiate from progression of anti-NMDAR encephalitis but there was no evidence in this cohort of increased antipsychotic sensitivity. Treatment with psychotropic medication should be individualised and adjusted during the course of the illness.

Revisiting lorazepam challenge test: Clinical response with dose variations and utility for catatonia in a psychiatric emergency setting.

OBJECTIVE: Catatonia can be life-threatening unless timely identified and treated. Lorazepam's ubiquitous response has led to its universal acceptance as being the first-line management of catatonia and alludes to catatonia's neurobiological underpinnings. Lorazepam challenge test (LCT) is widely used to either confirm a catatonia diagnosis or determine lorazepam sensitivity. It has a proposed schedule for administering lorazepam. However, efficacy of recommended LCT doses lack systematic evidence, resulting in variable LCT doses used in clinical and research settings contributing to findings that are challenging to generalize or assist with developing standardized lorazepam treatment protocols for catatonia. Given the same, this study aimed to objectively compare the response between two groups receiving different LCT doses and factors influencing the same. METHODS: The 6-month study in a psychiatric emergency setting at a tertiary neuropsychiatric center in India evaluated 57 catatonia patients, before and after administration of single 2 mg (n = 37; LCT-2) or 4 mg (n = 20; LCT-4) lorazepam dose, applying Bush Francis Catatonia Rating Scale (BFCRS), Mini International Neuropsychiatric Interview (MINI 5.0) and obtaining sociodemographic, clinical data. RESULTS: No between-group differences (LCT-2 vs LCT-4) for sociodemographic, clinical profiles or BFCRS severity score changes to lorazepam on Mann-Whitney U test were noted. Applying Wilcoxon signed rank test comparing individual sign severity demonstrated response variability, with significant response noted to both doses (stupor, mutism, staring, posturing, withdrawal, ambitendency, automatic obedience) and others selectively to 2 mg (echolalia, rigidity, negativism, mitgehen). Notably, sign resolution (present/absent) only to 2 mg was significant for stupor, mutism, staring, posturing, echolalia, rigidity, negativism and mitgehen. CONCLUSION: This study suggests 2 mg lorazepam may be an optimal LCT dose, given significant response to most catatonic signs thereby ensuring accurate detection and preventing misinterpretation of response. It offers future studies direction for standardizing lorazepam dosing schedules for catatonia management and exploring neurobiological underpinnings for individual catatonic signs that may be potentially different, given these findings.

Rapid efficacy of aripiprazole in the treatment of catatonic depression/catatonia with consideration of the drug's unique receptor profile: a case report.

Catatonia is a widespread problem in psychiatric hospitals as approximately 10% of patients present with catatonic symptoms upon admission. Catatonia carries the risk of severe, even fatal complications. The first line treatment is usually electroconvulsive therapy (ECT) or benzodiazepines, but ECT may not be readily available and benzodiazepines may not always be effective. We describe the case of a patient presenting with severe symptoms of catatonic depression who completed a 3-day course of 25 mg aripiprazole that rapidly resolved his catatonic symptoms. Several cases have already been reported where administration of aripiprazole successfully resolved catatonic symptoms after other treatment options had failed. Aripiprazole's efficacy and advantages may lie in its unique receptor profile. It acts as a dopamine D2 receptor (D2 R) antagonist and partial D2 R agonist depending on the precise cellular milieu, which may explain its efficacy and favourable side effect profile compared to other antipsychotics used to treat catatonia. Aripiprazole also partially agonises D3 receptors and serotonin 2 C receptors (5-HT2 C), which may contribute to its antidepressant properties. Aripiprazole enhances gamma-aminobutyric acid (GABA) transmission in certain brain areas, and it is widely agreed that low GABA activity may contribute to catatonic symptoms. Pharmacokinetics studies show that peak plasma levels are reached rapidly, within 2-3 hours of intramuscular administration and 4-6 hours of oral administration. Administration of high-dose aripiprazole (>25 mg/day) should be considered as a viable alternative to ECT and benzodiazepines in patients presenting with catatonic symptoms. Aripiprazole also carries a much lower risk of complications compared to other antipsychotics.

Serum and CSF Anti-NMDAR Antibody Testing in Psychiatry.

OBJECTIVE: The authors examined and compared the clinical presentation of CSF positive and negative N-methyl-d-aspartate receptor (NMDAR) antibody. METHODS: The investigators performed a retrospective chart review of NMDAR-antibody-positive cases (serum or CSF) involving patients presenting to psychiatric services from 2010 to 2018 in Queensland, Australia. Presentation, progress, investigations, and efficacy of treatment are detailed. RESULTS: There were 24 serum or CSF NMDAR-antibody-positive cases and three equivocal serum results. High rates of prodromal cognitive deficits, catatonia, speech disturbance, and antipsychotic sensitivity were observed in the 16 CSF NMDAR-antibody-positive case patients and two CSF NMDAR-antibody-negative case patients, all evident before neurological deterioration with seizures, movement disorder, and autonomic disturbance occurring in the weeks following admission. The majority of these patients (N=17) were treated successfully with immunomodulatory therapy. The nine remaining patients, who were CSF NMDAR antibody negative or equivocal, did not demonstrate any of these features and improved with psychiatric care alone. CONCLUSIONS: These findings suggest that traditional psychiatric care may be appropriate for patients with isolated psychiatric symptoms who have positive serum NMDAR testing when CSF is negative and there are no key clinical features such as cognitive deficits, catatonia, speech disturbance, and antipsychotic sensitivity. However, if these key features are present, a trial of immunomodulatory treatment should be considered with repeated examination of CSF for neuronal antibodies.

Treatment of Movement Disorder Emergencies in Autoimmune Encephalitis in the Neurosciences ICU.

Immune response against neuronal and glial cell surface and cytosolic antigens is an important cause of encephalitis. It may be triggered by activation of the immune system in response to an infection (para-infectious), cancer (paraneoplastic), or due to a patient's tendency toward autoimmunity. Antibodies directed toward neuronal cell surface antigens are directly pathogenic, whereas antibodies with intracellular targets may become pathogenic if the antigen is transiently exposed to the cell surface or via activation of cytotoxic T cells. Immune-mediated encephalitis is well recognized and may require intensive care due to status epilepticus, need for invasive ventilation, or dysautonomia. Patients with immune-mediated encephalitis may become critically ill and display clinically complex and challenging to treat movement disorders in over 80% of the cases (Zhang et al. in Neurocrit Care 29(2):264-272, 2018). Treatment options include immunotherapy and symptomatic agents affecting dopamine or acetylcholine neurotransmission. There has been no prior published guidance for management of these movement disorders for the intensivist. Herein, we discuss the immune-mediated encephalitis most likely to cause critical illness, clinical features and mechanisms of movement disorders and propose a management algorithm.

Catatonia-Like Syndrome Treated With Low-Dose Ketamine.

BACKGROUND: Ketamine's application in psychiatry have expanded, but it appears never to have been previously used to diagnose and treat patients with catatonia-like syndrome that occasionally present to emergency departments. CASE REPORT: A 23-year-old male was observed to suddenly stop talking. His ED GCS was 8 and had normal vital signs. While verbally unresponsive, he refused to open his eyes, demonstrated waxy flexibility of his arms, but the balance of his physical, neurological, and laboratory exams were normal. Strongly suspecting a catatonic state, they needed to rapidly confirm that diagnosis or begin evaluating him for potentially life-threatening non-psychiatric illnesses. Lacking other diagnostic modalities, they administered low-dose ketamine boluses. Ketamine 25 mg (1 mL) was diluted in 9 mL NS (2.5 mg/mL). Based on similar protocols, 1 mL of the solution (0.03 mg/Kg) was given intravenously every few minutes. After 12.5 mg ketamine, he was conscious and verbal. Subsequent history confirmed a prior episode requiring an extensive, non-productive medical evaluation. Psychiatry later confirmed the diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients with catatonia-like states pose a difficult diagnostic and therapeutic dilemma. Multiple interventions have been used with varying success. Optimal interventions provide a rapid resolution (or demonstrate that a psychiatric cause is not likely), be safe, encompass few contraindications, and be familiar to the clinician. In our patient, subanesthetic doses of ketamine fulfilled these criteria and successfully resolved the condition. If shown effective in other cases, ketamine would be a valuable addition to our psychiatric armamentarium.

[Catatonia, complicated withdrawal from benzodiazepines]. / Vignette thérapeutique de l'étudiant Syndrome catatonique lié à un sevrage compliqué en benzodiazépines.

The article describes a clinical case of catatonic syndrome. We describe the manifestations of the syndrome, its diagnostic criteria and associated scales. The modalities of the challenge test, constituting a diagnostic test, and first line treatment are detailed. Clinical and paraclinical investigations are proposed to determine the etiology. The benzodiazepine withdrawal as an etiology of catatonic syndrome is detailed.

L'article expose un cas clinique de syndrome catatonique. Nous y décrivons les manifestations du syndrome, ses critères diagnostiques et échelles associées. Les modalités du «challenge test¼, constituant une épreuve diagnostique, et le traitement de première ligne sont détaillés. Des investigations cliniques et paracliniques sont proposées afin d'en déterminer l'étiologie. Le sevrage en benzodiazépines comme étiologie du syndrome catatonique est discuté.

Benzodiazepines for catatonia in people with schizophrenia or other serious mental illnesses.

BACKGROUND: Catatonia is a debilitating disorder of movement and volition associated with schizophrenia and some other mental illnesses. People with catatonia are more likely to require hospitalisation and highly supervised care than those without the disorder. They also have an increased risk of secondary complications such as pneumonia, malnutrition and dehydration. The mainstay of treatment has been drug therapies and electroconvulsive therapy. OBJECTIVES: To compare the effects of benzodiazepines with other drugs, placebo or electroconvulsive therapy for catatonia in people with schizophrenia or other similar serious mental illnesses (SMIs). SEARCH METHODS: We updated our previous search (28 February 2007) by searching the Cochrane Schizophrenia Group's Study-Based Register of Trials (9 November 2016; 6 February 2019). This register is compiled by systematic searches of major resources (including CENTRAL, MEDLINE, Embase, AMED, BIOSIS, CINAHL, PsycINFO, PubMed, and registries of clinical trials) and their monthly updates, handsearches, grey literature, and conference proceedings, with no language, date, document type, or publication status limitations for inclusion of records into the register. We also manually searched reference lists from studies selected by the search. SELECTION CRITERIA: All controlled clinical trials that randomised people who have schizophrenia or other similar SMI and experiencing catatonia to receive benzodiazepines or another relevant treatment. We included studies that met our inclusion criteria and reported usable data. We excluded those not meeting our inclusion criteria or those not reporting usable data. We contacted authors when we required further information; and if we received no response, we put those studies aside as 'awaiting assessment'. DATA COLLECTION AND ANALYSIS: Review authors extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis using a fixed-effect model. We completed a 'Risk of bias' assessment for the included study and generated a 'Summary of findings' table using GRADE. MAIN RESULTS: The searches found 130 citations, from which we could identify 22 possibly relevant studies. From these, we could only include one study. This study had a relatively small sample size of 17 participants who received lorazepam or oxazepam and were drug free for one week before the trial started. The only usable data reported by this study were clinically important change in symptoms of catatonia measured as 50% improvement on the Visual Analogue Scale (VAS). There was no difference in the numbers of participants showing a clinically important change in their catatonic symptoms (RR 0.95, 95% CI 0.42 to 2.16; participants = 17; studies = 1; very low quality evidence).No data were reported for other important outcomes of hospital stay, clinically important change in satisfaction with care, global state, adverse effects or general functioningWe did find a few studies meeting our inclusion criteria but they reported no usable data. We had to exclude these. Although poorly reported, these studies do illustrate that relevant studies have been undertaken - they are not impossible to design and conduct. AUTHORS' CONCLUSIONS: Analysis of the results from this review, which was a head-to-head comparison of two benzodiazepine monotherapies, does not show a clear difference in effect. No data were available for benzodiazepines compared to placebo or standard care. The lack of usable data and very low quality of data available makes it impossible to draw firm conclusions and further studies with a high-quality methodology and reporting are required in order to determine more definitively the outcomes associated with benzodiazepine use in the clinical management of catatonia in persons with schizophrenia and other SMI.